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May 5, 2010

START Wars

by Tim Horn

There is a dearth of data from randomized clinical trials to demonstrate that the benefits of starting treatment when the CD4 cell count is above 350 outweigh the potential risks. Despite this paucity, a groundswell of support for early treatment is already growing.

As mentioned earlier, the San Francisco Department of Public Health (SFDPH) is now recommending ARV therapy be started as soon as HIV is diagnosed, regardless of the person’s CD4 cell count. Project Inform quickly followed suit, noting the potential personal and public health benefits that may come from early HIV treatment. Though Project Infom has quietly changed one its more controversial initial recommendations, Project Inform’s position statement continues to read as a strong endorsement for early treatment.

Bob Huff, a member of the AIDS Treatment Activists Coalition (ATAC), supports Project Inform’s original April 13 statement. “Based on what I understand about the evidence, and on what I understand about the potential benefits of treating HIV whenever it is diagnosed, I agreed with the position PI has taken,” Huff says. “I commended them for it because other AIDS organizations have avoided—or even actively resisted—supporting programs to greatly expand testing and treatment in their cities. I think PI understood it would be controversial but chose to make the statement anyway, and in doing so, I think, have showed some welcome leadership.”

Huff adds that immediate-treatment-for-prevention is a “reasonable approach” in an area like San Francisco, where the epidemic affects mainly gay men and where there has been “significant progress in expanding treatment access, which may have resulted in lowering community viral load rates. [Given results to date,] it makes sense [that public health officials] would press forward to try and achieve even more success. The potential payoff for the campaign would be halting the spread of new HIV infections in the area—an amazing outcome. Because the upside is so profound, it’s necessary that they try to achieve that goal.”

Mark Milano, another ATAC member and an activist with ACT UP New York, sees things differently. “I was unhappy with the simplistic advice the PI paper gave,” he says. “Unlike [deceased Project Inform founding director] Martin Delaney's vision of empowering people with HIV to take an active part in their health care decisions, PI just said, ‘We looked at the data, and we think you should start at 500.’ There was no attempt to educate people about the lack of data, nothing about the split on the DHHS panel, nothing about the ongoing debate over when to start. That’s not the approach I think Marty would have taken—he would have respected people with HIV enough to give them all points of view so they could decide for themselves.”

Milano also remains skeptical of the test-and-treat approach to combating the ongoing spread of HIV. “If these decisions were motivated by epidemiologic concerns—and I hope they weren’t—I disagree [with them]. Urging [people to start] treatment at higher CD4 counts when we don’t know the long-term effects, in an attempt to lower community-wide transmission rates [of HIV], does a real disservice to individuals making this life-changing decision. Especially if we don’t tell them [that protection of public health is] part of the motivation [for the recommendation].”

Collins adds: “An undetectable viral load on an individual level reduces the risk of transmission—this is supported by the data. But rolling out early treatment as a public health policy is different. An individual taking treatment primarily has to derive personal benefit, given that they face an individual risk from treatment. The discussion for individual treatment and public health cannot just be lumped together.”

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